Incidence, Prognosis and Predictors of Major Vascular Complications and Percutaneous Closure Device Failure Following Contemporary Percutaneous Transfemoral Transcatheter Aortic Valve Replacement.

OBJECTIVES: To determine the incidence, prognosis, and predictors of major Valve Academic Research Consortium (VARC-2) vascular complications (VCs) and percutaneous vascular closure device failure (PCDF) following contemporary percutaneous transfemoral transcatheter aortic valve replacement (TF-TAVR). BACKGROUND: Limited data exists on the incidence and predictors of VCs and PCDFs following percutaneous TF-TAVR using contemporary 14-16 French (F) sheaths. METHODS: We recorded clinical and procedural characteristics, computer tomography (CT) angiographic data, 30-day VCs, mortality, and length of stay (LOS) in all consecutive percutaneous TF-TAVRs at a single center from June 2016 to October 2018. CT measures included common femoral artery (CFA) and external iliac artery (EIA) diameters, sheath to CFA and EIA ratios (SFAR and SEIAR), depth of CFA, extent and location of CFA calcification and pelvic vessel tortuosity (2 bends ≥90°). Multivariable regression was used to predict major VCs and percutaneous closure device failure (PCDF), respectively. RESULTS: The final sample consisted of 303 percutaneous TF-TAVRs. Median age was 80 years, 51% were male, 86% Caucasian, 33% had diabetes mellitus (DM) and mean STS score was 5.8 ±â€¯3.8%. Baseline characteristics were similar in patients with vs. without VCs, other than coronary artery disease (CAD) (69% vs. 54%, respectively; p = 0.029) and DM (21% vs. 36%, respectively; p = 0.02). There were 65 (21%) vascular complications: 19 major VCs [6.3%], 29 minor [VCs 9.6%] and 17 PCDFs [5.6%]. Overall, 30-day mortality was low (2.6%). Major VCs were associated with higher mortality (42% vs. 0%, p < 0.0001) while minor VCs (3% vs. 0%, mortality p = 0.99) and PCDFs (3% vs. 0% mortality, p = 0.99) were not. PCDFs were associated with a longer median LOS (4 vs. 3 days, p = 0.02). The independent predictors of major VCs were pelvic vessel tortuosity (OR 3.1; 95% CI 1.1-9.2) and presence of CAD (OR 8.2; 95% CI 1.8-37). Female gender showed a strong trend toward increased risk (OR 3.4; CI 0.84-14; p = 0.086). There were no independent predictors of PCDF. CONCLUSION: Contemporary percutaneous TF-TAVR is associated with a low risk of mortality, major VCs and PCDFs. Major VCs confer increased mortality and PCDFs prolong LOS. Pelvic vessel tortuosity and a history of CAD predict major VCs; there were no predictors of PCDFs. These results provide a contemporary update on the incidence and implications of these important vascular complications in the current era of percutaneous TF-TAVR using 14-16F vascular sheaths.

Computed tomography-derived skeletal muscle index: A novel predictor of frailty and hospital length of stay after transcatheter aortic valve replacement.

To determine the prevalence of low skeletal muscle mass in patients undergoing transcatheter aortic valve replacement (TAVR) and whether skeletal muscle mass measured from preoperative computed tomography (CT) images provides value in predicting postoperative length of stay (LOS). BACKGROUND: There are limited data on the use of body composition as a frailty measure in TAVR patients and no studies have determined if this measure predicts LOS. METHODS: We studied 104 consecutive patients who underwent TAVR at Tallahassee Memorial Hospital from 2012 to 2016. Patient demographics, standard frailty measures (hand grip, albumin, and 5-m walk test), clinical comorbidities, echocardiographic data, and Valve Academic Research Consortium II major complications were recorded prospectively. Skeletal muscle index (SMI) [skeletal muscle mass cross-sectional area at L3/height2] was measured from CT images using Slice-O-Matic software (Tomovision, Montreal, Quebec, Canada). Clinical outcomes were assessed and multivariate methods used to determine predictors of LOS. RESULTS: Sarcopenia was prevalent in men (83%) and women (56%). Patients who suffered from a major complication had significantly longer length of stay (13 vs 4.6days, P<.0001). Skeletal muscle index correlated with age, sex, body mass index, handgrip strength, and previous coronary artery bypass graft surgery, but not major complications. A multivariate model including all univariate predictors of LOS showed SMI, major complications, transapical access, atrial fibrillation, and chronic obstructive pulmonary syndrome as independent predictors of LOS. For every 14-cm2/m2 increase in SMI, there was a 1-day reduction in LOS. None of the standard measures of frailty predicted LOS. CONCLUSIONS: Skeletal muscle index, a measure of sarcopenia readily determined from pre-TAVR CT scans, independently predicts TAVR LOS better than standard frailty testing. Further evaluation of SMI as a frailty measure after TAVR and other cardiovascular procedures is warranted.

Reevaluation of temporary transvenous cardiac pacemaker usage during carotid angioplasty and stenting: a safe and valuable adjunct.

Although many current series document the safety of carotid angioplasty and stenting procedures (CAS), several acknowledge clinically significant hemodynamic disturbances in 25-71% of patients. We report herein the safety and efficacy of prophylactic percutaneous temporary transvenous cardiac pacemaker insertion during CAS for the prevention of hemodynamic changes. At a community-based institution, 48 patients undergoing 51 attempted CAS procedures from March 1999 to August 2002 for carotid artery occlusive disease were retrospectively reviewed. Thirty-one percent of patients had procedures performed for either recurrent disease or a history of neck radiation; 62.5% had significant coronary disease. Temporary transvenous pacemakers were inserted as an adjunctive procedure in the authors' CAS protocol. The pacers were set to capture a heart rate decrease below 60 beats per minute. Demographics, cardiac risk, and outcomes were analyzed. CAS was successfully performed in 96% (49 lesions). In the intent-to-treat group, the patients had a mean age of 71 +/-9 years and angiographic stenoses of 88 +/-8%, with 29% having symptomatic lesions. Significant bradycardia or asystole to trigger ventricular pacing occurred in 11 (22%) procedures, thus, triggering ventricular pacing. Pharmacologic support for concomitant hypotension was temporarily necessary in only 4 (8%) cases. No patient required prolonged pacing or medication therapy following CAS. Neither presence of carotid-related symptoms nor disease etiology was related to need for intraprocedural pacing. Furthermore, there was no occurrence of pacemaker failure or other complication secondary to venous catheterization. Hemodynamic changes may occur during mechanical dilation of the carotid artery and bulb, with reports in the literature of the need for prolonged pharmacologic support. In selected patients, the prophylactic placement of a transvenous pacemaker is a safe, feasible, and expeditious method to treat periprocedural hemodynamic changes with a decrease in additional pharmacologic support during CAS.

Carotid artery stenting in a community setting: experience outside of a clinical trial.

Carotid artery angioplasty and stenting (CAS) currently represents a less invasive percutaneous alternative to conventional endarterectomy for the treatment of carotid occlusive disease. We report here the results and complication rates of CAS performed by a team of interventionalists at a non-clinical trial center utilizing a standardized CAS protocol. CAS was attempted in 51 arteries in 48 patients (mean age 71 +/- 9 years, range 53-90). Fifteen (29%) of 48 patients were symptomatic. Indications for CAS were previous ipsilateral endarterectomy (15/51, 29%), previous neck radiation therapy (1/51, 2%), or significant coronary artery disease (30/51, 59%). SMART((R)) stents were deployed via percutaneous femoral artery access, with anticoagulation (heparin, abciximab, aspirin, clopidogrel) and temporary transvenous cardiac pacemakers employed in all patients. Neuroprotection was not used. Neurological examination and duplex scans were performed in follow-up. CAS was successfully performed in 96% of cases (49 lesions/46 patients) with angiographic stenoses of 88 +/- 8%. Neurological complications included one (2%) minor stroke that occurred 12 hr after CAS. There were no periprocedural mortalities. Clinically significant bradycardia or asystole occurred in 11/49 (22%) procedures, necessitating short-term ventricular pacing. All stented vessels remained patent during 12.2 +/- 10.1 (range 1-37) months follow-up period. One asymptomatic restenosis (>70%) occurred at 3 months, which was successfully reangioplastied; we thus had 1-year angiographic restenosis rate of 2%. Patients selected for CAS may represent a subset of patients with carotid disease who have considerable comorbidities or unfavorable anatomy compared to those undergoing conventional endarterectomy. CAS may be performed safely outside of a clinical trial with results similar to those of published series from trial centers using a standardized protocol.

Endovascular management of a ruptured mycotic aneurysm of the innominate artery.

Mycotic aneurysms of the innominate artery are infrequent lesions and, as such, represent challenging surgical problems. We describe herein a case of a ruptured mycotic innominate artery aneurysm, which developed after radical neck dissection and radiation therapy for tonsillar carcinoma. The aneurysm was successfully excluded from the systemic circulation with endoluminal placement of a covered stent, with efficacy confirmed by vascular imaging at 6 months follow-up. The patient suffered no permanent neurologic sequelae. Long-term follow-up and chronic antibiotic therapy will be necessary to avoid infection of the covered stent in this high-risk surgical patient.